Three take away or Big Ideas from Carranza on Cardiovascular Disorders and Periodontal Disease
Hypertension

• Hypertension is the most common cardiovascular disease. This disease needs to be adequately controlled in order for the patient to receive treatment. Dental treatment for these patients is generally safe as long as stress is minimized.

• Many individuals go their dental office more frequently than their physician's office. It is important that at each appointment vitals are taken and recorded in the patient's records. This not only ensures that they safe to treat, but also provides a baseline to compare future readings to.

• JNC-7 guidelines for classification of Adult Blood Pressure:
  • Systolic B/P < 120 & Diastolic B/P < 80- Normal; no changes are needed for treatment
  • Systolic B/P 120-139 & Diastolic B/P 80-89- Prehypertension; no changes are needed for treatment; B/P should be monitored
  • Systolic B/P 140-159 & Diastolic B/P 90-99- Stage 1 hypertension; the patient should be informed of these findings and referred to their physician. For stage I hypertension there are still no changes in dental treatment, but stress should be minimized along with monitoring patient's B/P
  • Systolic B/P >160 & diastolic B/P >100- Stage 2 hypertension, the patient should be informed of these findings and referred to their physician along with monitoring the patient's B/P. IF the systolic B/P is < 180 & diastolic > 110, perform selective dental care and minimize stress. If systolic B/P is > 180 or diastolic is > 100 patient should be referred to their physician immediately and only emergency dental treatment should be performed with minimal stress.
• Patients that present with hypertension are usually put on Beta Adrenergic Blockers, or, antagonists. Many of the medication names commonly end with 'lol,' eg: nadolol, atenolol, and metoprolol.
• Beta blockers are either cardioselective ( blocking only B1) or nonselective ( blocking both B1 and B2). When administering anesthesia with w/epinephrine stimulation of both Alpha and Beta agonist occurs. Alpha stimulation creates vasoconstriction in the arteries and Beta stimulation causes vasodialation of the skeletal muscle arteries. When a patient is taking no selective Beta blockers, the compensatory B2 vasodialation and severe hypertension and bradycardia occur. It is important to know what type of beta blocker the patient is using. If they are using nonselective it is necessary to minimize the amount of epinephrine is administered to the patient with hypertension.

Infective Endocarditis

• Infective endocarditis is a great concern in the dental office, because dental procedures that involve bleeding may induce a transient bacteremia. The American Heart Association recommends antibiotic prophylaxis before procedures that will cause bleeding like periodontal surgery or a professional cleaning. The AHA also recommends that these patients maintain good oral hygiene to reduce bacteria in their mouths.
• Patients that have a history of infective Endocarditis (IE) prevention is of importance. The health history is an important tool to determine the susceptibility of the patient to IE. Proper oral hygiene is needed to reduce the quantity of bacteria in the oral cavity. Organisms that are in the oral cavity that can contribute to IE are Alpha hemolytic bacteria. It is important to start treatment slowly to decrease the amount of bleeding in the mouth. As the tissue heals more oral hygiene instruction can be implemented to reduce the bacteria in the mouth.

Congenital heart disease

Congenital heart disease occurs in about 1% of births. Cardiac defects can involve the heart, the adjacent vessels, or a combination of both. The most striking feature is cyanosis caused by shunting of deoxygenated blood from the right to left, resulting in a return of poorly oxygenated blood to systemic circulation. Chronic hypoxia causes impaired development, an increase in red blood cells, and clubbing of the fingers and toes. Polycythemia can result in increased bleeding (Carranza, 2006). Patients with congenital heart disease are at risk of infective endocarditis due to the blood flow in the heart and associated heart defects, because of this this patients should be evaluated prior to dental treatment to see if they will need a prophylactic antibiotic. These patients may also have cyanosis of the lips and oral mucosa, oral abnormalities which include:

• These defects change the flow of blood through the heart due to a portion of the heart not developing properly prior to birth
• Patient's suffering from congenital heart disease present with delayed eruption of both decidious and permanent teeth
• Increased positional abnormalities
• Enamel hypoplasia
• More severe periodontal disease
  • Due to at home oral hygiene practices
  • Also these patients don't generally seek out consistent treatment

Cardiovascular Accident
Results from ischemic changes or hemorrhagic phenomera. Hypertension and atherosclerosis are predisposing factors and should alert the clinician to evaluate the patient's medical history carefully. The clinician should counsel the patients about the importance of oral hygiene . Post strokes weakness of the facial are paralysis of extremities may make oral hygiene procedures difficulty for the patients. The clinician may need to modify the oral hygiene instruments for ease of use. Long term CHX rinses may be greatly aid in plaque control. (Carranza, 2006)